form test - IRMS Insurance and Risk Management Services

Contact Information

Client Name

Contact Name

First Last

Phone Number

Email Address

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

How did you find out about IRMS?

Other

Who is your current Auto Insurance Company:

What is the expiration date of your current policy?

Driver #1 Information

Name

First Last

Gender

Male
Female

Marital Status

What is the highest level of education you have completed?

Date of Birth

Drivers License #

Miles to work

Any Violations/Accidents? (Last 3 Years)

Additional Information

Good Student
Driver's Training
Student away at college

*Additional documentation may be needed for above.

Add a second driver?

Yes

Driver #2 Information

Name

First Last

Gender

Male
Female

Marital Status

What is the highest level of education you have completed?

Date of Birth

Drivers License #

Miles to work

Any Violations/Accidents? (Last 3 Years)

Additional Information

Good Student
Driver's Training
Student away at college

*Additional documentation may be needed for above.

Add a third driver?

Yes

Driver #3 Information

Name

First Last

Gender

Male
Female

Marital Status

What is the highest level of education you have completed?

Date of Birth

Drivers License #

Miles to work

Any Violations/Accidents? (Last 3 Years)

Additional Information

Good Student
Driver's Training
Student away at college

*Additional documentation may be needed for above.

Add a forth driver?

Yes

Driver #4 Information

Name

First Last

Gender

Male
Female

Marital Status

What is the highest level of education you have completed?

Date of Birth

Drivers License #

Miles to work

Any Violations/Accidents? (Last 3 Years)

Additional Information

Good Student
Driver's Training
Student away at college

*Additional documentation may be needed for above.

Type of vehicle

What type of vehicle(s) are you insuring?

Car, Truck, Van or SUV
Motorcycle

Vehicle #1 Information

Vehicle Information

Vehicle Year Vehicle Make Vehicle Model Vehicle Driver Number

Vehicle identification Number

Security Devices

Garaging Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Lien Holder

Vehicle Use

Add a second vehicle?

yes

Vehicle #2 Information

Vehicle Information

Vehicle Year Vehicle Make Vehicle Model Vehicle Driver Number

Vehicle identification Number

Security Devices

Garaging Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Lien Holder

Vehicle Use

Add a third vehicle?

yes

Vehicle #3 Information

Vehicle Information

Vehicle Year Vehicle Make Vehicle Model Vehicle Driver Number

Vehicle identification Number

Security Devices

Garaging Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Lien Holder

Vehicle Use

Add a fourth vehicle?

yes

Vehicle #4 Information

Vehicle Information

Vehicle Year Vehicle Make Vehicle Model Vehicle Driver Number

Vehicle identification Number

Security Devices

Garaging Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Lien Holder

Vehicle Use

Motorcycle #1 Information

Vehicle Information

Vehicle Year Vehicle Make Vehicle Model Vehicle Driver Number

Vehicle identification Number

Motorcycle Security Devices

Motorcycle Garaging Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Motorcycle Value

Motorcycle Engine CC's

Add a second motorcycle?

yes

Motorcycle #2 Information

Vehicle Information

Vehicle Year Vehicle Make Vehicle Model Vehicle Driver Number

Vehicle identification Number

Motorcycle Security Devices

Motorcycle Garaging Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Motorcycle Value

Motorcycle Engine CC's

Add a third motorcycle?

yes

Motorcycle #3 Information

Vehicle Information

Vehicle Year Vehicle Make Vehicle Model Vehicle Driver Number

Vehicle identification Number

Motorcycle Security Devices

Motorcycle Garaging Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Motorcycle Value

Motorcycle Engine CC's

Add a fourth motorcycle?

yes

Motorcycle #4 Information

Vehicle Information

Vehicle Year Vehicle Make Vehicle Model Vehicle Driver Number

Vehicle identification Number

Motorcycle Security Devices

Motorcycle Garaging Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Motorcycle Value

Motorcycle Engine CC's

Coverage Information

Bodily Injury Liability

Property Damage Liability

Uninsured Motorist Limits

Uninsured Motorist

Medical Payments

Personal Injury Protection

Comprehensive Deductible

Collision Deductible

Towing

Rental

Motorcycle Endorsement

Any Additional Comments

By Checking this Box, you certify that all information provided is accurate.*

Are you currently a client of IRMS?*

If yes, who is your agent*:

If no, have you spoken to any of the following agents?*

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